At 1930, assumed care after receiving report from offgoing nurse. Patient observed in bed, awake, alert, and oriented ×4. Telemetry displayed sinus rhythm. Patient reported head pain rated 6/10 and declined offered ordered analgesics. Patient oriented to room and use of call light. Assumed care of new patient after receiving report from offgoing nurse. Patient…

Report received from offgoing nurse regarding patient plan of care. Patient observed in bed, asleep, with family present at bedside. Respirations observed even and unlabored. No use of accessory muscles noted. Patient denies pain when asked. Lines / Drains: Foley catheter in place, draining yellow urine. Safety: Bed in lowest position with wheels locked. Call…

Received patient during handoff. Patient noted to be in non-behavioral soft restraints to bilateral upper extremities (right and left wrists). Indication: risk of harm to self related to pulling at lines/tubes. Active restraint order verified in EMR and current. Skin to restrained extremities intact with no redness, breakdown, or swelling noted at this time. Patient…